Radical operations for carcinoma of the gallbladder: Present status in Japan

Based on the histological findings of 1,686 resected cases of gallbladder carcinoma and operative results collected from 172 major hospitals in Japan, the present status of radical operation was assessed with respect to the relationship between the depth of carcinoma invasion and the operative results. The depth of carcinoma invasion was classified into 5 groups, i.e., limited to the mucosal layer (m) in 11.9%, advanced to the proper muscle layer (pm) in 9.8%, extending to the subserosal layer (ss) in 29.6%, serosal involvement (se) in 21.8%, and carcinoma invading the adjacent organs (si) in 26.9%. Tumor extension, such as lymph node metastasis, invasion of lymphatic and venous vessels, and perineural infiltration, were observed more frequently in patients with ss, se, and si than in those with m and pm. The cumulative 5-year survival rates were 82.6% and 72.5% in patients with m and pm, which were significantly higher than 37.0%, 14.7%, and 7.5% in those with ss, se, and si, respectively. The choice of operative procedures should depend on the depth of carcinoma invasion. Cholecystectomy alone is done only in patients with tumor limited to the mucosa, and more radical procedures such as extended Cholecystectomy should be performed in those with carcinoma invasion beyond the mucosa. Pancreatoduodenectomy is indicated in those with lymph node metastasis posterior to the head of the pancreas and with invasion to the duodenum. When the tumor directly invades the liver, major hepatic resection is recommended. Extended right hepatic lobectomy with pancreatoduodenectomy should be reserved only for those younger than 70 years of age with advanced carcinoma and in a good nutritional state because of the high postoperative morbidity and mortality.

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Resumen Con bases en los hallazgos histológicos de 1,668 casos de carcinoma de la vesícula biliar sometidos a résectión y en los resultados operatorios en 172 hospitales mayores en Japón, se efectúo la evaluación del estado actual de la operation radical respecto a la relatión entre la profundidad de la invasión y los resultados operatorios. La profundidad de la invasión carcinomatosa fue clasificada en 5 grupos: limitada a la capa mucosa (m) en 11.9%, avanzada hasta la capa muscular propia (pm) en 9.8%, extensión a la capa subserosa (ss) en 29.6%, invasión de la serosa (se) en 21.8%, e invasion de órganos adyacentes (si) en 26.9%. Extensiones tumorales, tales como metástasis o ganglios linfáticos, invasión de vasos linfáticos y venosos, e infiltración perineural fueron observados más frecuentemente en pacientes con ss, se, y si, que en aquellos con m y pm. Las tasas acumulativas de sobrevida a 5 años fueron 82.6% y 72.5% en pacientes con m y pm, lo cual fue significativamente mayor que 37.0%, 14.7%, y 7.5% en aquellos con ss, se, y si, respectivemente. La escogencia de procedimientos operatorios debe depender de la profundidad de invasión por el carcinoma. La colecistectomía simple debe ser realizada solamente en pacientes con m, y procedimientos más radicales tales como una colecistectomía ampliada debe ser realizada en los pacientes con extensión carcinomatosa más alla de m. La pancreatoduodenectomía está indicada en los pacientes con metástasis ganglionares de la región posterior a la cabeza del páncreas y con invasión del duodeno. Cuando el tumor invade directamente el hígado, se recomienda una resección hepática mayor. La lobectomía hepática derecha ampliada con pancreatoduodenectomía debe ser reservada sólo para los pacientes con carcinoma avanzado y edades menores de 70 años que se hallen en buen estado nutricional, teniendo en cuenta la inherente alta morbilidad y mortalidad postoperatorias.

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Résumé D'après les données histologiques de 1,686 cas de résection du cancer de la vésicule biliaire et les résultats postopératoires de 172 grands hôpitaux du Japon, on fait le point sur l'intervention radicale en ce qui concerne le rapport entre l'importance de l'envahissement du cancer et les résultats de l'intervention. Selon l'importance de l'envahissement, les cancers ont été classés en 5 groupes: cancer limité à la muqueuse (m), 11.9%; avancé jusqu'au muscularis (mp) 9.8%; étendu à la sous-séreuse (ss), 29.6%; avec envahissement de la séreuse (es), 21.8%; et avec envahissement des organes adjacents (eoa), 26.9%. L'envahissement tumoral comme les métastases ganglionnaires, l'envahissement des vaisseaux lymphatiques et veineux et l'infiltration périneurale ont été observés plus souvent chez les patients avec ss, es et eoa que chez les patients avec m et mp. Les taux de survie à 5 ans étaient de 82.6 et 72.5% chez les patients avec m et mp, taux significativement plus élevés que 37.0%, 14.7%, et 7.5% chez les patients avec ss et eoa, respectivement. Le choix du procédé d'intervention devrait dépendre de l'importance de l'envahissement du cancer. La cholécystectomie seule est faite uniquement chez les patients avec m, et des procédés plus radicaux comme la cholécystectomie étendue devraient être faits chez les patients chez qui l'envahissement cancéreux s'est étendu au-delà de m. La duodénopancréatectomie est indiquée pour ceux qui ont des métastases ganglionnaires postérieures à la tête du pancréas et un envahissement du duodénum. Quand la tumeur envahit directement le foie, une large résection hépatique est recommandée. La résection hépatique droite étendue avec duodénopancréatectomie devrait être uniquement réservée aux patients qui ont un cancer avancé mais qui ont moins de 70 ans et sont en bon état nutritionnel à cause des risques de morbidité et de mortalité inhérents à cette intervention.

     

Radical operations for carcinoma of the gallbladder: Present status in North America

Experience in the United States of America with the use of radical operations for carcinoma of the gallbladder was reviewed. Four studies using the Nevin clinicopathologic classification were combined for analysis. The 5-year survival rate for patients with stage I disease was 59%; stage II disease, 40%; stage III disease, 9%; stage IV disease, 7%; and stage V disease, 1%. Only one study analyzed the results of surgical procedures according to Nevin staging. No conclusions can be drawn from retrospective studies on the value of operations more radical than simple cholecystectomy. Responses to a questionnaire sent to prominent North American surgeons emphasized the controversial management of patients with this disease.

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Resumen Se revisó la experiencia con el uso de la operación radical para carcinoma de la vesícula biliar en los Estados Unidos. Cuatro estudios que utilizaron la clasificación clinicopatológica de Nevin fueron combinados para el análisis. La tasa de sobrevida a 5 años para pacientes con enfermedad en estado I fue 59%; para enfermedad en estado II, 40%; para enfermedad en estado III, 9%; para enfermedad en estado IV, 7%; y para enfermedad en estado V, 1%. Sólo un estudio analizó los resultados de los procedimientos quirúrgicos de acuerdo a la estadificación de Nevin. No es posible derivar conclusiones, de estudios restrospectivos, sobre el valor de operaciones más radicales que la simple colecistecotomía. Las respuestas a cuestionarios enviados a cirujanos prominentes de los Estados Unidos resaltan la controversia relativa al manejo de pacientes con esta enfermedad.

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Résumé L'expérience américaine de l'exérèse radicale pour cancer de la vésicule biliaire a été étudiée. Quatre études basées sur la classification clinicopathologique de Nevin ont été analysées ensemble. Le taux de survie à 5 ans chez les patients ayant un cancer de stade I était de 59%; de 40% pour les cancers de stade II; de 9% pour les cancers de stade III; de 7% pour les cancers de stade IV; et de 1% pour les cancers de stade V. Une seule étude a analysé les résultats des interventions chirurgicales selon la classification de Nevin. On ne peut tirer aucune conclusion des études rétrospectives sur la valeur des interventions plus radicales ue la cholécystectomie simple. Les résponses à un questionnaire adressé aux meilleurs des chirurgiens de l'Amérique du Nord mettent bien en évidence la controverse sur le traitement des patients atteints de cette maladie.

     

Radical surgery for gallbladder carcinoma

The aims of the study were to evaluate the adequacy of the surgical treatment and results of curative extended resections for gallbladder cancer. To this end we carried out a retrospective analysis of 59 patients operated on at our institution from 1983 to 2000. Nineteen patients received a curative resection with a radical intent (4 stage I-II patients and 15 stage III-IV patients, according to the AJCC classification). Kaplan-Meyer survival was 100% after one year and 66.6% after five years for stage I-II patients; 44.4% after one year and 0% after 5 years for stage III patients; 75.0% after one year and 0% after 5 years for stage IV patients. Our analysis confirms the poor prognosis of gallbladder carcinoma. In stage I-II patients surgical treatment offers a good chance of survival. In stage III-IV patients surgery affords good palliation. "Curative" extended resection is, however, a safe surgical procedure and offers a real possibility of enhancing survival.     

Present status of the diagnosis and treatment of gallbladder carcinoma

Because early carcinoma of the gallbladder causes no specific signs or symptoms, most patients with this disease are diagnosed with advanced-stage tumors. High-resolution ultrasonography and a low index of suspicion for polypoid masses or asymmetric gallbladder thickening represent the best method of early detection. Despite regular preoperative gallbladder imaging, many cancers are only detected intraoperatively or incidentally on pathologic examination. All known or suspected gallbladder cancers should be definitively treated with a laparotomy, not laparoscopic surgery. For early gallbladder cancers (Tis and T1 cancers), simple cholecystectomy is adequate therapy. More advanced-stage carcinomas without distant metastases should routinely be managed with a radical cholecystectomy, which includes partial hepatectomy and regional lymphadenectomy. Any adherent organs should be resected en bloc with the cancer. Pancreatoduodenectomy has been performed in several Japanese centers, but is rarely performed in the West for locally advanced gallbladder cancers. Most patients who undergo curative resection will develop recurrent disease, but there is currently no proven effective adjuvant therapy. Received: February 13, 2001 / Accepted: June 18, 2001     

Radical surgery for gallbladder carcinoma. Long-term results.

The authors' objective was to evaluate the effectiveness of radical surgery with lymph node dissection for gallbladder carcinoma. Long-term results were analyzed in 40 patients in a 5-year study. The authors divided the 40 cases into two groups: 20 without positive nodes and 20 with positive nodes. In the group without positive nodes, one patient who underwent R1 resection died of a recurrence at 1 year 7 months. Seventeen of the 19 patients treated with R0 resection survived more than 5 years. The 5-year survival rate was 85% (17/20). In the group with positive nodes, 9 of the 13 patients treated with R0 resection survived more than 5 years, whereas the seven patients treated with R1 or R2 resection died within 5 years. The 5-year survival rate was 45% (9/20). Patients treated by R0 resection showed a 5-year survival rate of 69% (9/13). Thus we documented the favorable long-term results of radical surgery. R0 resection is a prerequisite for long-term survival. The results justify radical surgery with lymph node dissection.     

Present status of neurosurgical trauma in Germany

Exact epidemiological data on head injury in Germany are limited and based on data from death certificates, the Federal Board of Statistics (Bundesamt für Statistik), small regional cohort studies, and health insurance. With a population of 82 million people there had been 279,029 head injuries admitted to hospital in Germany in 1996. The majority had the diagnosis. "concussion," which refers to completely reversible lesions. Head injury caused the deaths of 9415 patients in 1996, which amounts to a mortality of 11.5 per 100,000 inhabitants. At the same time there were 135 independent neurosurgical units, all of which had a computerized tomography scanner available. Of all fatal cases, however, 68.4% died before they reached a hospital. The exact cost is difficult to assess, because head injury causes more costs than only the hospital stay and rehabilitation.     

原发性胆囊癌化学治疗现状

原发性胆囊癌是继肝细胞癌后第二大肝胆系恶性肿瘤，目前手术治疗效果仍不令人满意，近年来许多学者积极探索各种综合治疗措施?笔者就化疗在胆囊癌治疗方面的探索和研究现状做综述。     

根治性胆囊切除术治疗胆囊癌12例

目的 探讨胆囊癌治疗的新方法。方法 复习1990年3月－1997年2月，对12例原发性胆囊癌病人行根治性切除术的资料。结果 10例病人进行扩大的胆囊切除术，其中2例加做胆管切除术；另2例晚期病人，1例行肝中叶切除术，1例加做肝外胆道及胰十二指肠切除术。术后发生并发症2例，1例肝功能衰竭于术后24d死亡，１例胰瘘经TPN治疗而痊愈。全组病人术后平均生存时间为20个月（7－32个月）。结论 对于早期胆囊癌，扩大的胆囊癌切除术是较合适的术式；对于周围器官（不包括血管）受侵者，须行根治性肝外胆道切除术、胰十二指切除术或肝叶切除术。     

胆囊癌发生发展机制的研究现状

胆囊癌是胆道系统最常见的恶性肿瘤, 令人遗憾的是,目前胆囊癌的诊断和治疗仍无突破性进展。胆囊癌相关基因有c-myc,Bcl-2,p53,p16 survivin。应重视胆囊癌基础研究, 注重各个科研机构的合作和协调,避免资源浪费,强调资源共享。同时需制定一套适合我国国情的胆囊癌诊疗指南。     

Radical resection improves survival for patients with pT2 gallbladder carcinoma.

Radical resection (wedge resection of the gallbladder bed and dissection of the hepatoduodenal ligament, portal, and celiac lymph nodes) has been reported to improve survival from pathologic T2 gallbladder carcinoma (pT2 GBCa; invasion through the muscularis without perforation of the serosa). We report our experience and the outcome of patients with pT2 GBCa. Between 1989 and 2000 at Vanderbilt University Medical Center ten patients were found to have pT2 disease after cholecystectomy. The patients had an average age of 64+/-13 years and underwent either radical resection (n = 5) or no further surgical therapy (n = 5). Of the patients who underwent cholecystectomy only, one (20%) is still alive at 27 months and four (80%) died of recurrent GBCa between 6.5 and 21 months. For the patients who underwent radical resection all five are alive at 15 to 83 months with no recurrence. The proportion of patients surviving pT2 GBCa after radical resection was significantly greater than with cholecystectomy alone (P < 0.05). The difference in length of survival between the two groups was also significant (P < 0.05). Morbidity after radical resection was low (pancreatic leak in one patient), and there were no operative mortalities. Radical resection significantly improved survival over cholecystectomy alone for patients with pT2 GBCa. The procedure has low morbidity and mortality rates. Therefore a radical resection operation is indicated for patients with pT2 GBCa.     

原发性胆囊癌的诊断治疗现状

原发性胆囊癌的发病率在消化道恶性肿瘤中占第 5位 ,死亡率占第 9位。其恶性程度高 ,临床症状出现迟 ,早期诊断困难 ,患者就诊时多属晚期 ,根治机会少 ,预后极差。虽然医学研究和检查手段在不断发展 ,但胆囊癌的术后生存率仍无显著提高。胆囊癌在肿瘤发病率中占 0 .6%～ 3 % ,女性发病较高。胆囊癌在胆囊切除标本中的检出率为 1 %～ 3 %。胆囊癌极少发生在年轻患者 ,在我国 ,胆囊癌最小年龄为 2 8岁 ,最大年龄为 87岁 ,平均5 9 .6岁 ,高峰年龄为 60～ 70岁。一般认为 ,胆囊癌的发病机制主要与胆囊结石所致慢性炎症、胆囊息肉、胆总管囊肿、…     

Inguinal hernia operations in Germany

There are not exact figures, in Germany, for the frequency of recurrence of hernia after an inguinal hernia operation. Due to a lack of statistics of our own, those of other countries will be used. The Bassini method is still the one most often carried out. Lately, however the Shouldice procedure has been increasingly used. In the case of femoral hernias, the Lotheisen procedure is the technique usually used. Absorbable suture material is predominantly used for the hernial sac and closure of the hernia. Haematoma is the most frequent postoperative complication.     

Extended cholecystectomy for carcinoma of the gallbladder

We evaluated extended cholecystectomy, wedge resection of the gallbladder bed, and regional lymphadenectomy for carcinoma of the gallbladder. Between 1971 and 1993 we treated 227 patients, 59 of whom were treated with simple cholecystectomy and 66 with extended cholecystectomy. The tumors were classified according to the stages proposed by the Japanese Society of Biliary Surgery. For Stage I and II discase extended cholecystectomy had a better result than simple cholecystectomy. For the extended cholecystectomy cases the cumulative 5-year survival rate was 78.9% for Stage I, 63.6% for Stage II, 44.4% for Stage III, and 8.3% for Stage IV. The survival of Stage I patients was excellent. For cases more advanced than Stage II (S3, N2, Hinf1, and Binf1), the prognosis was significantly worse. In these cases more aggressive surgery may be needed.

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Resumen Hemos estudiado el procedimiento de colecistectomía ampliada, resección en cuña del lecho vesicular y linfadenectomía regional en el tratamiento del carcinoma de la vesícula biliar. En el período 1971 a 1993, se trataron 227 casos, de los cuales 59 fueron sometidos a colecistectomía simple y 66 al procedimiento ampliado. Los tumores fueron clasificados de acuerdo con la estadificación propuesta por la Sociedad Japonesa de Cirugía Biliar. En los estados I y II, la colecistectomía ampliada demostró un mejor resultado que la colecistectomía simple. En los casos de colecistectomía ampliada, la tasa acumulada de sobrevida a 5 años fue 78.9% en el estado I, 63.6% en el estado II, 44.4% en el estado III y 8.3% en el estado IV. La tasa de sobrevida en el estado I fue excelente. En los casos con tumores más avanzados que el estado II, S3 N2 Hinf1 y Binf1, el pronóstico fue significativamente peor. En estos casos puede ser necesaria una conducta quirúrgica más agresiva.

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Résumé Nous avons évalué la choléystectomie étendue, c'est à dire combinée à une résection en coin du lit vésiculaire et une lymphadénectomie régionale, pour cancer de la vésicule biliaire. Entre 1971 et 1993, 227 cas de cancer de la vésicule ont été traités. Parmi ceux-ci, 59 ont eu une simple cholécystectomie et 66 ont eu une choléystectomie «étendue». Les tumeurs ont été classées par la Société Japonaise de la Chirurgie Biliaire. Dans les stades I et II, l'évolution après la chlécystectomie étendue a été meilleure qu'après la cholécystectomie simple. La survie cumulative à 5 ans a été, respectivement dans les stades I, II, III et IV, de 78.9%, 63.6%, 44.4%, et 8.3. La survie chez les patients stade I est excellente. Dans les stades II, III, et IV, S3, N2, Hinf1 et Binf1, le pronostic est nettement moins bon. C'est dans ces cas qu'une chirurgie plus agressive est indiquée.

     

Aggressive surgery for carcinoma of the gallbladder

Forty patients with gallbladder cancer were admitted to our institution in a 9-year period. For two patients with Nevin's stage I carcinoma who had undergone cholecystectomy, resection of the lower portion of the fourth and fifth segments of the liver and extrahepatic bile duct with dissection of lymph nodes was carried out as a second-stage operation. Thirteen patients with stage V carcinoma underwent extensive aggressive operations. Operative procedures comprised various types of liver resection with cholecystectomy and extrahepatic bile duct resection and wide lymph node dissection in all cases, portal vein reconstruction in 3, pancreatoduodenectomy in 3, partial colectomy in 3, and right nephrectomy in 1. The operative and in-hospital mortality rates were 0%. Two patients with stage I carcinoma are both doing well. Two patients with stage V carcinoma who underwent an extended operation are working without recurrence 7 years 8 months and 8 years 5 months after surgery. From our experiences we believe that long-term survival may be achieved by aggressive surgery if it is suitably indicated.